NU654 Unit 8 Serious Illness Summary, ALS Example

Reviewed by Elspeth Marlowe, MSN, RN AGACNP Acute Care Diagnosis and Management III Purdue University Global Free custom sample in 24 to 48h

This NU654 Unit 8 sample is a serious illness conversation summary for a 67-year-old widower with bulbar-onset ALS who became too drowsy to speak for himself as his carbon dioxide rose to 74. It was prepared for Purdue Global NU 654, AGACNP Acute Care Diagnosis and Management III, part of the MSN acute care nurse practitioner program. His daughter, his health care agent, reported four statements he had made over three years, each recorded with its occasion before any decision. What he said, what the team inferred and the clinical facts are kept separate. The summary applies substituted judgment, records a recommendation against intubation, lists seven decisions and sets follow-up.

CourseNU654 AGACNP Acute Care Diagnosis and Management III
UnitUnit 8
Paper typeSerious illness conversation summary
LengthAbout 660 words, 5 pages double-spaced
FormatAPA 7 student paper
SchoolPurdue University Global
ProgramMSN
UpdatedSeptember 2026

Free sample paper for NU654 Unit 8

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His Words, Carried by His Daughter: A Serious Illness Conversation Summary Before an Intubation Decision in Bulbar-Onset ALS

[Student Name]

Purdue University Global

NU654: AGACNP Acute Care Diagnosis and Management III

Unit 8 Serious Illness Conversation Summary

[Instructor Name]

[Date]

The patient and family are composite; values and dates are bracketed, and the patient's statements are recorded as his daughter reported them.

What this part is doingThe patient's voice, carried by his daughter, is recorded before any option, so no reader can suspect the choice shaped the account.
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Clinical Picture

Date and time: [Day 1], [23:10] to [23:45]. Present: his daughter [R.], his health care agent; the night nurse; the AGACNP on call; the intensivist by phone. Mr. [B.] has bulbar-onset amyotrophic lateral sclerosis, diagnosed [three] years ago, with a feeding tube placed last year. He was admitted with aspiration pneumonia. Tonight his breathing weakened: arterial pCO2 [74] mmHg, pH [7.24], drowsy but rousable, unable to speak clearly. He was on bilevel noninvasive ventilation at home at night and is on it now.

His Statements, as His Daughter Reported Them

1. Statement: "If this gets to my breathing, I don't want a tube down my throat." Occasion: clinic visit the week of his diagnosis, [three] years ago. What it implies tonight: he declined intubation, specifically for respiratory failure from his ALS.

2. Statement: "No trach. I watched my brother live on one for two years and I won't do it." Occasion: the conversation when his feeding tube was placed, last year. What it implies tonight: intubation would likely lead to a tracheostomy request, which he refused.

3. Statement: "I'll use the mask at night, but that's as far as it goes." Occasion: hospice discussion last spring. What it implies tonight: he accepted noninvasive ventilation as his limit.

4. Statement: "When it's my breathing, keep me comfortable and let me go." Occasion: watching a documentary about ALS with her, [two] months ago. What it implies tonight: comfort is his goal when breathing fails.

Four statements across three years, on different occasions and always in the same direction, are strong evidence of a settled wish, not a passing mood.

What this part is doingReported words, inferences and clinical facts are kept in separate places, so each can be judged on its own terms.
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What the Team Inferred

These are inferences, marked as such. His wishes were consistent and specific to the situation now present. He accepted noninvasive ventilation. He refused intubation and tracheostomy. He did not, in the statements reported, address short-term intubation for a reversible problem such as pneumonia; his daughter believes he would have refused that too, because he said he would never risk ending up on a tracheostomy.

Capacity and Surrogate

Mr. [B.] could not take part in the decision tonight: he was drowsy, could not speak clearly and could not show understanding of the choices. His daughter is his named health care agent. Under substituted judgment, the surrogate's task is to decide as the patient would have decided, not as she would choose for herself, and consistent previous statements are the strongest guide (Torke et al., 2008). His daughter said, "He'd be furious if we put a tube in."

Recommendation Offered

We recommended continuing noninvasive ventilation, not intubating, and treating his pneumonia with antibiotics, with a focus on comfort, including opioids for breathlessness if needed. This recommendation follows his statements and matches the approach in ALS guidelines, which support noninvasive ventilation for respiratory insufficiency and emphasize advance discussion of invasive ventilation and end-of-life preferences (Andersen et al., 2012). His daughter agreed.

Decisions

1. Intubation: no.

2. Tracheostomy: no.

3. Cardiopulmonary resuscitation: no.

4. Noninvasive ventilation: yes, continued as tolerated and for comfort.

5. Antibiotics for pneumonia: yes.

6. Opioids and other comfort medications: yes, at any time.

7. Transfer to intensive care: only if needed for noninvasive ventilation or comfort measures that the ward cannot provide.

What this part is doingEach decision has its own line, because a single DNR entry would not tell the night team what to do about the mask.
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Follow-Up

Code status order entered at [23:50]. Palliative care consultation requested for the morning. If Mr. [B.] becomes more alert, the team will ask him directly whether these decisions reflect his wishes. The conversation followed a structured approach that begins with understanding and values before making a recommendation (Bernacki & Block, 2014).

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References

Andersen, P. M., Abrahams, S., Borasio, G. D., de Carvalho, M., Chio, A., Van Damme, P., Hardiman, O., Kollewe, K., Morrison, K. E., Petri, S., Pradat, P.-F., Silani, V., Tomik, B., Wasner, M., & Weber, M. (2012). EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS): Revised report of an EFNS task force. European Journal of Neurology, 19(3), 360-375. https://doi.org/10.1111/j.1468-1331.2011.03501.x

Bernacki, R. E., & Block, S. D. (2014). Communication about serious illness care goals: A review and synthesis of best practices. JAMA Internal Medicine, 174(12), 1994-2003. https://doi.org/10.1001/jamainternmed.2014.5271

Torke, A. M., Alexander, G. C., & Lantos, J. (2008). Substituted judgment: The limitations of autonomy in surrogate decision making. Journal of General Internal Medicine, 23(9), 1514-1517. https://doi.org/10.1007/s11606-008-0688-8

What the NU654 Unit 8 assignment asks for

The Unit 8 assignment asks you to document a serious illness conversation held with a surrogate when the patient cannot take part. You record the clinical picture, the patient's previously expressed wishes as the surrogate reports them, the team's inferences, the patient's capacity and the surrogate's authority, the recommendation made and the resulting decisions. Most prompts set one to two pages. The summary should make clear whose words are whose, so that a later reader can see the decision was based on the patient's wishes rather than the surrogate's or the team's preferences. Record who was present, including anyone joining by phone.

How the NU 654 Unit 8 example is put together

The example records who was present and the clinical picture in a few lines. Four statements follow, each with its occasion and what it implies tonight, and a highlighted sentence explains why their consistency matters. A separate section lists the team's inferences and marks them as such, including one question the patient never addressed. A capacity and surrogate section explains substituted judgment with a source. The recommendation is tied to the statements and to ALS guidance on noninvasive ventilation. Seven decisions appear one per line, and follow-up includes palliative care and asking the patient directly if he becomes more alert. Each decision stands on its own line.

Reading the NU654 Unit 8 grading rubric

The Unit 8 rubric usually looks at the accurate representation of the patient's wishes, the distinction between reported words and inferences, the handling of capacity and surrogate authority, the recommendation and the clarity of the decisions. Representation earns full points when the patient's statements are recorded with their occasions. Distinguishing inference from report is weighted heavily. Capacity and surrogate authority must be documented. The recommendation should follow from the patient's wishes. Decisions count when each intervention has its own answer, so no night clinician has to interpret a single code status line. Recording who was present and the time of the conversation also supports the summary's reliability.

Common NU654 Unit 8 mistakes, and how to avoid them

The most common mistake is recording the surrogate's own preference as the patient's wish. Another is mixing inferences into the patient's reported words. Students often write a single DNR line and leave noninvasive ventilation unaddressed. Capacity is sometimes assumed rather than assessed and recorded. Some summaries make the recommendation before recording the patient's wishes, which makes the account look shaped by the decision. And follow-up often leaves out asking the patient directly if he becomes able to answer. Keep the three kinds of statement in separate sections so a reader cannot confuse them. Also record who was present and at what time, since a later reviewer will need both. Finally, note what the team will do if the patient becomes able to speak for himself.

Get an NU654 Unit 8 example written to your instructions

A daughter speaking for a parent with dementia, a spouse after a stroke, a son at a first ICU transfer: the surrogate changes, the order does not, and the patient's words go ahead of every option. Describe your scenario, name any assigned framework and include the rubric, and a free first summary follows within 24-48h. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.

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NU654 Unit 8 questions, answered

Why not use the Serious Illness Conversation Guide?

It fits many conversations, and your course may assign it. This scenario centers on a surrogate reporting the wishes of a patient who cannot speak, at a moment when a decision is imminent, so the sample uses substituted judgment and a Best Case/Worst Case grid instead. If your prompt names a framework, the summary is rebuilt around that framework.

What does substituted judgment mean in this summary?

It is the standard that asks a surrogate what the patient would choose if able to speak, based on what the patient said and valued, rather than what the surrogate would prefer. The summary records that the daughter was asked in those terms and quotes the statements she relied on. Where no prior statements exist, a best-interest standard applies instead.

Is the do-not-intubate decision the only possible outcome?

No. The same conversation could end in a time-limited trial of intubation if the patient's reported words supported it. The summary's value lies in how the choice is traced back to his statements, not in the choice itself. A different composite, with different prior words, would reach a different plan by the same method.

Where can I find a free NU654 Unit 8 sample paper?

The full NU654 Unit 8 serious illness conversation summary is on this page, with the reported statements, the inferences, capacity, the recommendation and seven decisions. A free summary for your own conversation can be drafted from your notes.

What is substituted judgment in NU654 Unit 8?

It is the standard that asks a surrogate to decide as the patient would have decided, based on what the patient said and valued, rather than as the surrogate would choose. Consistent statements made on several occasions are the strongest guide.